{"id":453,"date":"2019-08-12T07:37:27","date_gmt":"2019-08-12T07:37:27","guid":{"rendered":"http:\/\/biotehnos.in.ua\/?page_id=453"},"modified":"2025-04-24T20:07:57","modified_gmt":"2025-04-24T17:07:57","slug":"obrashhenie-farmakonadzor-potrebitel","status":"publish","type":"page","link":"https:\/\/biotehnos.in.ua\/en\/farmakonadzor\/obrashhenie-farmakonadzor-potrebitel\/","title":{"rendered":"Patient&#039;s request to a pharmacovigilance expert at Biotechnos LLC"},"content":{"rendered":"<div class=\"wpcf7 no-js\" id=\"wpcf7-f455-o1\" lang=\"ru-RU\" dir=\"ltr\" data-wpcf7-id=\"455\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/453#wpcf7-f455-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"\u041a\u043e\u043d\u0442\u0430\u043a\u0442\u043d\u0430\u044f \u0444\u043e\u0440\u043c\u0430\" novalidate=\"novalidate\" data-status=\"init\" data-trp-original-action=\"\/en\/wp-json\/wp\/v2\/pages\/453#wpcf7-f455-o1\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"455\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.4\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"ru_RU\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f455-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<h5>\n\t<center>CARD-NOTIFICATION for providing information by the patient and\/or his representative about an adverse reaction (hereinafter referred to as ADR) of a medicinal product (hereinafter referred to as MD), and\/or lack of efficacy (hereinafter referred to as EE) of a MD\n\t<\/center>\n<\/h5>\n<h5>\n\t<center>Patient information\n\t<\/center>\n<\/h5>\n<p><label>Name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-1-form-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"f-1-form-2\" \/><\/span><\/label><br \/>\n<label>Name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"n-1-form-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"n-1-form-2\" \/><\/span><\/label><br \/>\n<label>Patronymic<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"fn-1-form-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"fn-1-form-2\" \/><\/span><\/label><br \/>\n<label>Address<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"adress-1-form-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"adress-1-form-2\" \/><\/span><\/label><br \/>\n<label> Tel.\/Fax<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"phone-1-form-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"phone-1-form-2\" \/><\/span><\/label>\n<\/p>\n<h5>\n\t<center>Information about the suspected drug\n\t<\/center>\n<\/h5>\n<p>Trade name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tn-1-form-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"tn-1-form-2\" \/><\/span><br \/>\n<label> Release form<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"form-1-form-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"form-1-form-2\" \/><\/span><\/label><br \/>\n<label>Producer<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"whudo-1-form-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"whudo-1-form-2\" \/><\/span><\/label><br \/>\n<label>The suspect drugs were prescribed to the patient by a doctor<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"yes-or-not-1-form-2\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"yes-or-not-1-form-2\" value=\"\u0422\u0430\u043a\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"yes-or-not-1-form-2\" value=\"\u041d\u0456\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/label><br \/>\n<label>The patient used the suspected drugs without a doctor&#039;s prescription.<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"yes-or-not-2-form-2\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"yes-or-not-2-form-2\" value=\"\u0422\u0430\u043a\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"yes-or-not-2-form-2\" value=\"\u041d\u0456\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/label><br \/>\n<label>Description of drug adverse reactions and\/or indications of drug EOs<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"description-1-form-2\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"description-1-form-2\"><\/textarea><\/span><\/label>\n<\/p>\n<h5>\n\t<center>Information about the reporter\n\t<\/center>\n<\/h5>\n<p><label>Name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-2-form-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"f-2-form-2\" \/><\/span><\/label><br \/>\n<label>Name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"n-2-form-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"n-2-form-2\" \/><\/span><\/label><br \/>\n<label>Patronymic<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"fn-2-form-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"fn-2-form-2\" \/><\/span><\/label><br \/>\n<label>Address<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"adress-2-form-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"adress-2-form-2\" \/><\/span><\/label><br \/>\n<label> Tel.\/Fax<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"phone-2-form-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"phone-2-form-2\" \/><\/span><\/label><br \/>\n<label> Email address<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"email-1-form-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email-1-form-2\" \/><\/span><\/label>\n<\/p>\n<h5>\n\t<center>Information about the doctor, healthcare facility, and place of residence of the patient who experienced a drug adverse reaction and\/or drug adverse reaction\n\t<\/center>\n<\/h5>\n<p><label>Name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-3-form-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"f-3-form-2\" \/><\/span><\/label><br \/>\n<label>Name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"n-3-form-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"n-3-form-2\" \/><\/span><\/label><br \/>\n<label>Patronymic<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"fn-3-form-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"fn-3-form-2\" \/><\/span><\/label><br \/>\n<label>Location of the healthcare facility (Address)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hbl-1-form-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hbl-1-form-2\" \/><\/span><\/label><br \/>\n<label>Name of the healthcare facility where the attending physician works<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nb-1-form-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nb-1-form-2\" \/><\/span><\/label><br \/>\n<label> Tel.\/Fax<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"phone-3-form-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"phone-3-form-2\" \/><\/span><\/label><br \/>\n<label> Patient&#039;s place of residence (Address)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pl-1-form-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pl-1-form-2\" \/><\/span><\/label>\n<\/p>\n<p><span style=\"margin-bottom: 10px;\">\n\t<\/span>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Send\" \/>\n<\/p><input type='hidden' class='wpcf7-pum' 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